Litigation related to drug errors in anaesthesia: an analysis of claims against the NHS in England 1995–2007

Abstract

SummaryNinety‐three claims (total cost £4 915 450) filed under ‘anaesthesia’ in the NHS Litigation Authority database between 1995 and 2007, alleging patient harm directly by drug administration error or by an allergic reaction, were analysed. Alleged errors were categorised using systems employed by the National Coordinating Council for Medication Error Reporting and Prevention, the American Society of Anesthesiologists Closed Claims Project and the UK Health and Safety Executive. The severity of outcome in each claim was categorised using adapted National Patient Safety Agency definitions. Sixty‐two claims involved alleged drug administration errors (total cost £4 283 677) and 15 resulted in severe harm or death. Half alleged the administration of the wrong drug, in most (16) a neuromuscular blocker. Of the claims alleging the wrong dose had been given (25), nine alleged opioid overdose including by neuraxial routes. The most frequently recorded adverse outcomes were awake paralysis (19 claims; total cost £182 347) and respiratory depression requiring intensive care treatment (13 claims; total cost £2 752 853). Thirty‐one claims involved allergic reactions (total cost £631 773). In 20 claims, the patient allegedly received a drug to which they were known to be allergic (total cost £130 794). All claims in which it was possible to categorise the nature of the error involved human error. Fewer than half the claims appeared likely to have been preventable by an ‘ideal double checking process’.

Treatment with Epinephrine (Adrenaline) in Suspected Anaphylaxis during Anesthesia in Denmark

“…33 In this study anaphylaxis was reported in 31 patients, and in 20 of these a drug was given despite a known allergy; there were no deaths or sequelae in this group. However, in the remaining 11 patients, the cause of the reaction was unknown, and thus the reaction was unexpected.…”

Litigation related to regional anaesthesia: an analysis of claims against the NHS in England 1995–2007*

“…NAP3 highlighted nine cases (six in obstetrics) of wrong-route injection errors, where a drug planned for neuraxial administration was accidentally injected intravenously, or vice versa. There was one clear wrong-route error involving the wrong drug administered into an epidural catheter (in obstetric theatre recovery) and three others that may have been wrong-dose or wrong-route errors (one theatre based and two ward-based, all non-obstetric) [29]. There were no claims relating to accidental intravenous administration of epidural drugs, nor of the wrong drug given intrathecally.…”

Delayed awakening following inadvertent high-dose remifentanil infusion in a 13 year old patient

“…Studies analyzing anesthesia-related deaths concur that the majority of accidents in modern anesthesia practice are the consequence of human error [3]. Mistakes, lack of vigilance, inexperience, inadequate supervision, and communication failures are identified as recurring problems.…”